<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name" data-rule="required" class="form-control" name="row[name]" type="text" value="{$row.name}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Level')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-level" data-rule="required" class="form-control" name="row[level]" type="number" value="{$row.level}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Intro')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-intro" class="form-control " rows="5" name="row[intro]" cols="50">{$row.intro}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Price')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-price" data-rule="required" class="form-control" step="0.01" name="row[price]" type="number" value="{$row.price}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Ward')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-ward" data-rule="required" class="form-control" name="row[ward]" type="number" value="{$row.ward}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Surgery_ward')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-surgery_ward" data-rule="required" class="form-control" name="row[surgery_ward]" type="number" value="{$row.surgery_ward}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Special_ward')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-special_ward" data-rule="required" class="form-control" name="row[special_ward]" type="number" value="{$row.special_ward}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Escort_vip')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-escort_vip" data-rule="required" class="form-control" name="row[escort_vip]" type="number" value="{$row.escort_vip}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Escort')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-escort" data-rule="required" class="form-control" name="row[escort]" type="number" value="{$row.escort}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Escort_halfday')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-escort_halfday" data-rule="required" class="form-control" name="row[escort_halfday]" type="number" value="{$row.escort_halfday}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Register')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-register" data-rule="required" class="form-control" name="row[register]" type="number" value="{$row.register}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Inquiry')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-inquiry" data-rule="required" class="form-control" name="row[inquiry]" type="number" value="{$row.inquiry}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Document')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-document" data-rule="required" class="form-control" name="row[document]" type="number" value="{$row.document}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicine')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicine" data-rule="required" class="form-control" name="row[medicine]" type="number" value="{$row.medicine}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Records')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-records" data-rule="required" class="form-control" name="row[records]" type="number" value="{$row.records}">
        </div>
    </div>
    <!--<div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Escort_overtime')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-escort_overtime" data-rule="required" class="form-control" name="row[escort_overtime]" type="number" value="{$row.escort_overtime}">
        </div>
    </div>-->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Severe_illness')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-severe_illness" data-rule="required" class="form-control" name="row[severe_illness]" type="number" value="{$row.severe_illness}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Oversea')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-oversea" data-rule="required" class="form-control" name="row[oversea]" type="number" value="{$row.oversea}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Private_doctor')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-private_doctor" data-rule="required" class="form-control" name="row[private_doctor]" type="number" value="{$row.private_doctor}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Famous_doctor')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-famous_doctor" data-rule="required" class="form-control" name="row[famous_doctor]" type="number" value="{$row.famous_doctor}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Status')}:</label>
        <div class="col-xs-12 col-sm-8">
            
            <div class="radio">
            {foreach name="statusList" item="vo"}
            <label for="row[status]-{$key}"><input id="row[status]-{$key}" name="row[status]" type="radio" value="{$key}" {in name="key" value="$row.status"}checked{/in} /> {$vo}</label> 
            {/foreach}
            </div>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
